Feature
Subarachnoid haemorrhage:
case study and literature review
Jim Bethel explains the signs and symptoms of
this form of stroke and discusses the treatment
options open to emergency care professionals
Summary
More younger people are affected by subarachnoid haemorrhage (SAH) than by
any other form of stroke, and fatality rates are high (van Gijn et al 2007). Classic
signs and symptoms include sudden onset of ‘thunderclap’ headache but patients
can present with atypical symptoms such as neck stiffness. For patients who
survive SAH, the psychosocial consequences can be devastating and can affect
their families or carers. This article describes the management of one patient who
attended an emergency department with atypical symptoms of SAH, and discusses
the incidence of, investigations into, and treatment for SAH.
Keywords
Subarachnoid haemorrhage, berry aneurysm, ‘thunderclap’ headache
The fatality rate for subarachnoid haemorrhage
(SAH) after aneurysm rupture, at up to 50 per cent
(van Gijn et al 2007), is high. Between 10 and
15 per cent of patients with SAH die before they
arrive at hospital (Huang and van Gelder 2002)
and those who survive are often left with profound
disabilities (Kaptain et al 2000).
About 13 per cent of patients who present to
emergency departments (EDs) with sudden onset
of severe headache have sustained SAHs (de Falco
2004) yet their headaches are often attributed to
benign causes. Clinicians must therefore be aware of
the risk factors, signs and symptoms that indicate an
underlying subarachnoid bleed (Table 1).
The incidence of SAH increases with age but the
average age of people with SAH is 50, compared
with 65 for those with other forms of stroke
(Anderson et al 2000). Eighty five per cent of SAHs
are sustained secondary to a ruptured aneurysm,
such as a berry aneurysm (van Gijn et al 2007),
and between 7 and 20 per cent of people with SAH
after aneurysm have close relatives who have had
intracranial aneurysms (Kaptain et al 2000).
22 April 2010 | Volume 18 | Number 1
Most patients with subarachnoid bleeds present
with severe headaches that have developed within
seconds. These headaches, which patients may
describe as the worst they have ever had, often
follow physical exercise, including sex. They
also often occur in patients who have made a
forced expiratory effort against a closed airway,
known as the Valsalva manoeuvre, for example
when lifting a heavy weight, which can produce
tachycardia and an increase in blood pressure.
(Kaptain et al 2000, Peters et al 2004, Spratt et al
2007, van Gijn et al 2007)
The College of Emergency Medicine guidelines
on the management of lone acute severe headache
(LASH), or ‘thunderclap’ headache, highlight that
speed in diagnosing SAH is vital to optimise the
prognosis and that, in the absence of trauma and
fever, any presentation of LASH should be assumed
to be SAH until proven otherwise (Ferguson 2004).
Although LASH is a cardinal sign of SAH,
up to 13 per cent of patients present without
headache but with neck pain (Ahmed et al 2007,
Naganuma et al 2008).
Other signs and symptoms of SAH include
nausea, vomiting, photophobia, a decreased level
of consciousness and focal neurological deficits
such as unsteady gait, hemiparesis or facial palsy
(Kaptain et al 2000, Higashida et al 2006).
About 7 per cent of patients have a seizure on
aneurysmal rupture and, although some regain full
consciousness, they usually remain drowsy, confused
or agitated (van Gijn et al 2007).
Neck stiffness is a common feature of SAH,
secondary to the inflammatory response in
the subarachnoid space, although it can take
between three and 12 hours to become evident
(van Gijn et al 2007).
EMERGENCY NURSE
 Feature

Almost 20 per cent of patients with SAH report

Science Photo Library

mild to moderate headaches, known as ‘sentinel
headaches’, in the days or weeks before they become
severe. Patients with sentinel headaches have a ten
times higher risk of re-bleed after the first SAH
compared with those who do not (McBeath and
Nanda 2000, Beck et al 2006, Higashida et al 2006,
Valença et al 2007).

Investigations
Computed tomography (CT) can detect up to
97 per cent of subarachnoid bleeds within 24 hours
of presentation and up to 75 per cent within
72 hours of presentation (Kaptain et al 2000,
Thomson et al 2000, Dodick 2002).
However, only 18 per cent of patients who present
at EDs with SAH have CT scans within two hours of
arrival, and about 33 per cent have to wait for more
than six hours. Such waiting times delay diagnosis
and treatment (Thomson et al 2000, Chen et al 2006).
Other authors highlight inadequate history
taking in EDs as a factor in delayed or inaccurate Computed tomography scan showing subarachnoid haemorrhage
diagnosis of SAH and recommend the development
of assessment and management guidelines that the specific location and extent of the bleed can be
are based on the factors associated with SAH identified by CT angiography (Cook 2008).
(Locker et al 2004). Some authors argue that, because CT
It is accepted generally that the absence angiography can identify candidates for surgery
of blood on a CT scan does not exclude SAH more quickly than lumbar puncture, it should
(Watson et al 2008) so, if SAH is suspected but not be the first intervention when SAH is suspected
indicated by CT, patients should undergo lumbar (Sen et al 2008).
puncture (Dupont et al 2008) at least 12 hours
after presentation. Treatment
Lumbar puncture can reveal xanthochromia, In patients with SAH, the risk of re-bleeding is high.
which can be caused by the presence of red Up to 15 per cent experience re-bleeding after initial
blood cells in the cerebrospinal fluid. It should SAHs (Okhuma et al 2001) and prognosis after
be remembered, however, that, in patients with re-bleed is poor; 80 per cent die or have permanent
hyperbilirubinuraemia, xanthochromia can be major disabilities such as post-traumatic stress
confused with bilirubin abnormalities (Carley disorder or cognitive impairment (Roos et al 2000).
and Harrison 2004).
Where CT scans offer no evidence of raised Table 1 Signs and symptoms of an underlying subarachnoid bleed
intracranial pressure, and when fundoscopy reveals
no papilloedema, the risk of brain herniation caused Presentation ■■ Sudden onset of ‘worst headache ever’.
by lumbar puncture is negligible (van Crevel et al
2002). Documented episodes of herniation after Medical history ■■ Previous subarachnoid haemorrhage (SAH) or diagnosis
lumbar puncture relate mainly to meningeal of berry aneurysm.
infections, in which herniation complicates up to ■■ Hypertension.
5 per cent of lumbar punctures, although their ■■ Family history of SAH or other intracranial aneurysms.
causal link is debated (Shetty and Steele 1999, Joffe
2007). In cases of suspected SAH, therefore, CT Associated ■■ Smoking.
should always precede lumbar puncture. high-risk behaviour ■■ Alcohol use.
The combination of a negative CT scan and ■■ Cocaine use.
negative lumbar puncture performed 12 hours after ■■ Pregnancy.
presentation is considered a safe and effective way ■■ Use of oral contraceptives.
to exclude SAH (Locker et al 2004, Perry et al 2008). (Weir et al 1998, Kaptain et al 2000, Larkin-Their et al 2007)
If SAH is diagnosed by one of these two methods,

EMERGENCY NURSE April 2010 | Volume 18 | Number 1 23

 Feature
Alamy
If haemorrhage is suspected, lumbar puncture may be needed
In patients with SAH who are not comatose
or moribund, therefore, early surgical intervention
is advocated (Whitfield and Kirkpatrick 2001,
van Gijn et al 2007).
The Hunt and Hess (1968) classification for SAH
should be used to estimate the severity of patients’
illnesses (Table 2), their prognoses and their
suitability for surgical intervention. The prognosis
for patients with Grade 4 or 5 SAH, for example,
is poor and so these patients are less likely than
those with Grade 1, 2 or 3 SAH to be considered for
surgery (Molyneux et al 2002).
Antithrombolytic therapy is not advocated in
the treatment of SAH (Roos et al 2003, Carley and
Sen 2005) although oral nimodipine, a calcium
antagonist, is considered an important adjunct
for reducing ischaemia after bleeding (Dorhout
Mees et al 2002, Brown and Carley 2004).
Codeine or other opiate-based analgesia are
recommended for controlling the pain associated
Table 2 Classification of subarachnoid haemorrhage
Grade 1 Asymptomatic or with mild headache, slight nuchal rigidity.
Grade 2 Moderate or severe headache, nuchal rigidity, no neurological deficit
except cranial nerve palsy.
Grade 3 Drowsy, minimal neurological deficit.
Grade 4 Stuporous, moderate to severe hemiparesis, early decerebrate rigidity.
Grade 5 Deeply comatose, decerebrate rigidity, moribund.
(Hunt and Hess 1968)
24 April 2010 | Volume 18 | Number 1
with SAH. Assessment and appropriate management
of pain is important because, if this pain is
untreated, it can raise intracranial pressure and
exacerbate the symptoms of SAH (Cook 2008).
Airway management and respiratory support for
moribund patients can be critical, and practitioners
should be aware that, even in conscious and lucid
patients, clinical sequalae can develop suddenly.
Psychosocial consequences
The long lasting consequences of SAH
include cognitive impairment, mood
disturbance, fatigue and sleep difficulties
(Morris et al 2004, Schuiling et al 2005, Samra et al
2007, Schneider et al 2007).
Because patients with SAH tend to be
younger than those with other forms of stroke
(Anderson et al 2000), they tend to be of working age
and more likely to have dependent children.
In some studies, up to 54 per cent of survivors
of SAH confess to feeling depressed after the acute
events, while 25 per cent say that they would rather
have died than to live with their residual disabilities
(Buchanan et al 2000, Pritchard et al 2001).
According to Hedlund et al (2008), patients’
concerns focus on:
■■ Loss of good relationships with partners, often
leading to separation and divorce, or with close
family members due to illness and associated
changes in lifestyle. In some cases, however,
relationships are strengthened.
■■ Loss of normal work and home lives, and of
the ability to undertake physical activities such
as driving. Because of these losses, partners
and other family member may have to take on
new responsibilities.
■■ Psychological changes such as cognitive deficits,
problems with concentration, memory loss,
depression, fear and anticipatory anxiety.
Evidence suggests partners, other family members
and carers also have trouble adjusting to changes in
their relationships with people who have sustained
SAH (Mezue et al 2004, Cook 2008).
Many partners, family members and carers have
financial problems because their ability to work has
been compromised.
In addition, their personal and social life can
be restricted, and they are likely to experience
stress and anxiety about their loved ones having
further bleeds (Hop et al 2001, Pritchard et al 2001,
Mezue et al 2004, Noble and Schenck 2008).
Studies reveal that 50 per cent of these partners,
family members and carers think that they suffer as
much as the people who have sustained SAH, and
26 per cent of them think that they would rather
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Case study
A 48-year-old man presented at an emergency
department (ED) with gradual onset of a right-sided
headache, which had worsened over the previous
few days and had not responded to simple analgesia
such as paracetamol.
The patient said that he had experienced a similar
headache a year ago and that this had been caused
by a subarachnoid bleed from a then undiagnosed
berry aneurysm, for which he had undergone
neurosurgery. This previous bleed had left him
with a mild left-sided paralysis, problems with
concentration, and memory loss.
The patient had no associated symptoms, such
as photophobia or vomiting, and no other medical
history of note. He was not overweight, had never
smoked and used a gym regularly. He worked as
a civil engineer, was married and had two children.
After giving details of his medical and social history,
the patient became upset and began to cry, saying
that he recognised the signs and symptoms of
cerebral bleed from his earlier illness, and that
he feared he would die or be incapacitated from
a further bleed.
Acknowledgement of his fears and insight was an
important part of the assessment process, and the
author discussed with him how the two of them
planned to proceed. His wife was called and his
presentation and plan of care was described.
The patient did not want to contact his children
at that time because they were in school.
The patient’s physiological parameters were
normal. He was neither hypertensive nor febrile,
and fundoscopy revealed no intraocular linear or
flame-shaped haemorrhage, which are indicative
be dead than continue living in their new situations
(Buchanan et al 2000, Pritchard et al 2004, Noble
and Schenck 2008).
In view of these factors, clinicians should
consider the short and longer term challenges that
face patients and their families when planning care
for survivors of SAH.
Case study
The patient described in the case study above
presented with atypical symptoms of SAH. The onset
of the headache was gradual rather than sudden,
EMERGENCY NURSE April 2010 | Volume 18 | Number 1 25
Feature
of raised intracranial pressure. He made no complaint
of visual disturbance.
The patient was given codeine-based analgesia and
was cannulated. Half-hourly neurological observations
were begun. A full blood count was made,
urea and electrolyte concentrations were assessed,
and a clotting screen was undertaken. In addition,
a computed tomography (CT) scan was requested
and took place 15 minutes later, about 30 minutes
after the patient had been registered in the ED.
While waiting for the CT scan results, he complained
of mild photophobia and nausea. The CT scan results
were found to be normal and the surgical clipping of
his previous aneurysm was noted.
The author spoke to the neurosurgical team at the
tertiary care centre in which the patient had been
treated previously. They advised that he did not need
surgical intervention at this time and so referral to
them was unjustified.
In view of the patient’s medical history and evolving
symptoms, however, the author referred him to
the on-call hospital medical team and he was
transferred immediately to the medical assessment
unit where a lumbar puncture was undertaken.
This revealed xanthochromia, which was assumed
to be caused by the presence of red blood cells in
his cerebrospinal fluid.
About 30 minutes after the lumbar puncture was
undertaken, the patient complained of a sudden
increase in the severity of his headache. He then
collapsed and had a cardiac arrest. Resuscitation
attempts were unsuccessful and, at about two hours
after he had presented to the ED, he was declared
dead. Post-mortem results revealed that he had had
a further subarachnoid haemorrhage.
and the patient described it as moderate rather than
severe. However, because of his past medical history,
a cautious and detailed assessment was undertaken.
The gradual onset headache with which he
presented may have been a sentinel headache,
as described in the literature, so a CT scan was
performed and was found to be negative.
Because it was assumed that onset of symptoms
had begun more than 12 hours earlier, a lumbar
puncture was performed and the presence of
xanthochromia was confirmed. As a result, an SAH
was diagnosed.
 Feature

Unfortunately, the patient’s fears about his

prognosis were realised and he died from a further
Implications for practice
SAH before either his wife or children could see him. All clinicians working in first-contact care This article has been subject
It is likely that the patient’s family members environments should be aware of the lone acute to double-blind review
had lived with the fear of a recurrent bleed for the severe headache guidelines. Where subarachnoid
12 months since the patient’s first illness and that James Bethel is senior lecturer
haemorrhage (SAH) is indicated, patients should in emergency care at the
they had faced at least some of the psychosocial receive computed tomography investigations rapidly. University of Wolverhampton,
consequences of SAH described in the article. In addition, consideration should be given to the and nurse practitioner in the
The incident remains disturbing to the emergency departments of
psychosocial consequences of SAH for patients, Walsall Hospitals NHS Trust
practitioners involved in this case because of the and to their families and carers, where appropriate. and Sandwell and West
patient’s prescience about his outcome. Birmingham Hospitals NHS Trust

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